HESI RN MATERNITY EXAM
2026/2027 PRACTICE QUESTIONS
155 | VERIFIED ANSWERS &
RATIONALES | ELSEVIER EVOLVE
NCLEX-RN READINESS | INSTANT
DOWNLOAD PDF
1. A client in active labor at 6 cm dilation requests epidural anesthesia. Which
laboratory value should the nurse review as a priority before administration?
A. Hemoglobin
B. White blood cell count
C. Platelet count
D. Blood glucose
Rationale: Before epidural placement, the platelet count must be assessed because
thrombocytopenia significantly increases the risk of epidural hematoma and spinal
cord compression. Low platelets (typically below 50,000–100,000/mm³, depending on
facility protocol) are a contraindication .
2. One hour after delivery, the nurse is unable to palpate the uterine fundus of
a client and notes a large amount of lochia on the perineal pad. Which
intervention should the nurse implement next?
A. Document the number of pad changes
B. Increase the rate of the oxytocin infusion
C. Palpate the suprapubic area for bladder distention
D. Provide a bedpan to void if unable to ambulate
Rationale: A boggy, displaced uterus with excessive lochia strongly suggests uterine
atony, most commonly caused by a full bladder. The bladder displaces the uterus
upward and to the right, preventing effective contraction. The nurse must first assess
for bladder distention; increasing oxytocin without emptying the bladder will be
ineffective .
3. A nurse is assessing a 2-hour-old newborn and notes a bluish tinge to the
tongue. Which action should the nurse take?
,A. Document the finding as acrocyanosis
B. Obtain current vital signs and notify the provider immediately
C. Apply a pulse oximeter to the foot
D. Reassess the infant in 30 minutes
Rationale: A bluish tinge to the tongue (central cyanosis) indicates systemic hypoxemia
and represents a life-threatening emergency, often due to right-to-left shunting in
congenital heart defects. Peripheral cyanosis (acrocyanosis) of the hands and feet is
common and less concerning, but central cyanosis takes priority .
4. A client at 30 weeks of gestation is on bed rest at home for increased blood
pressure. She calls the clinic complaining of "indigestion." Which instruction
should the nurse provide?
A. Take an antacid and call back if pain persists
B. Lie on the left side and call 911 for emergency assistance
C. Take your blood pressure now and if it is seriously elevated, go to the
hospital
D. See your healthcare provider for a prescription for a histamine blocker
Rationale: Indigestion in pregnancy, especially with a history of elevated blood
pressure, may signal serious complications like preeclampsia or cardiac issues. The
priority is to assess blood pressure to determine if emergency care is needed .
5. The nurse is evaluating a full-term multigravida who was induced 3 hours
ago. The monitor indicates that the fetal heart rate decelerates at the onset of
several contractions and returns to baseline before each contraction ends.
Which action should the nurse take?
A. Reapply the external transducer
B. Insert an intrauterine pressure catheter
C. Continue to monitor labor progress
D. Discontinue the oxytocin infusion
Rationale: The described pattern is early deceleration, which is caused by head
compression during contractions and is a benign finding. It mirrors the contraction and
returns to baseline before the contraction ends. No intervention is required other than
continued monitoring .
6. A new mother is having trouble breastfeeding. The newborn is making
frantic rooting motions and will not grasp the nipple. Which intervention by
the nurse would be most helpful?
A. Encourage the mother to continue attempting to latch despite the distress
B. Ask the mother to stop feeding, comfort the infant, and then assist the
,mother to help the baby latch on
C. Recommend formula supplementation until the infant is calmer
D. Suggest the mother pump and bottle-feed instead
Rationale: Frantic rooting and failure to grasp the nipple indicate the infant is overly
hungry or stressed, making effective latching impossible. The best approach is to calm
the infant first (skin-to-skin contact, gentle rocking) and then assist with proper
positioning and latch technique when the infant is more relaxed .
7. A nurse is caring for a client with suspected placental abruption. Which
finding is most consistent with this diagnosis?
A. Painless bright red vaginal bleeding
B. A rigid, board-like abdomen
C. Sudden severe pain with fetal distress in a client with a prior uterine scar
D. Regular uterine contractions before 37 weeks gestation
Rationale: A rigid, board-like abdomen in a pregnant client is a classic sign of abruptio
placentae (placental abruption), which occurs when the placenta separates prematurely
from the uterine wall. Placenta previa typically presents with painless, bright red
bleeding .
8. The healthcare provider prescribes magnesium sulfate 1 gram per hour IV for
a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in
dextrose 5% in water 500 mL. How many mL/hour should the nurse program
the infusion pump?
A. 10 mL/hour
B. 20 mL/hour
C. 25 mL/hour
D. 50 mL/hour
Rationale: The concentration is 20 grams in 500 mL = 0.04 grams/mL. The prescribed
dose is 1 gram/hour. Using the formula: 1 gram/hour ÷ 0.04 grams/mL = 25 mL/hour.
The nurse must monitor for magnesium toxicity (absent reflexes, respiratory
depression) and keep calcium gluconate available as the antidote .
9. A client at 38 weeks gestation reports a sudden gush of clear fluid from the
vagina. Which action should the nurse take first?
A. Check the fluid for a nitrazine reaction
B. Notify the healthcare provider
C. Assess the fetal heart rate
D. Perform a sterile speculum examination
, Rationale: After spontaneous rupture of membranes, the priority is assessing fetal well-
being because of the risk of umbilical cord prolapse. Checking fluid characteristics,
notifying the provider, and speculum examination are important but secondary to
confirming fetal safety .
10. A postpartum client who is Rh-negative gave birth to an Rh-positive
newborn but did not receive Rho(D) immune globulin. The nurse understands
this places the client at risk for which condition in a future pregnancy?
A. ABO incompatibility
B. Hemolytic disease of the newborn
C. Hyperbilirubinemia in the current newborn
D. Maternal thrombocytopenia
Rationale: Without Rho(D) immune globulin, an Rh-negative mother produces anti-Rh
antibodies that attack Rh-positive fetal red blood cells in a subsequent pregnancy,
causing hemolytic disease of the newborn .
11. A nurse is teaching a client about signs of preterm labor. Which statement
by the client indicates correct understanding?
A. "I should call if I feel regular contractions even without pain."
B. "Menstrual-like cramps are normal and not a concern."
C. "Low back pain is always just muscular."
D. "Increased vaginal discharge only means infection."
Rationale: Regular contractions, pelvic pressure, low back pain, menstrual-like cramps,
and changes in discharge may indicate preterm labor and should be reported .
12. A nurse is evaluating a client's understanding of home care for mastitis.
Which statement indicates a need for further teaching?
A. "I will finish all my antibiotics even if I feel better."
B. "I should stop breastfeeding from the infected breast."
C. "Warm compresses before feeding help with comfort."
D. "I will increase my fluid intake to stay hydrated."
Rationale: Breastfeeding or pumping from the infected breast helps empty it and
reduces bacterial stasis. Stopping worsens engorgement and infection. The client should
continue feeding from both breasts, starting on the unaffected side .
13. A client is admitted with suspected placental abruption. Which finding is
most consistent with this diagnosis?
A. Painless bright red vaginal bleeding
B. A rigid, board-like abdomen
2026/2027 PRACTICE QUESTIONS
155 | VERIFIED ANSWERS &
RATIONALES | ELSEVIER EVOLVE
NCLEX-RN READINESS | INSTANT
DOWNLOAD PDF
1. A client in active labor at 6 cm dilation requests epidural anesthesia. Which
laboratory value should the nurse review as a priority before administration?
A. Hemoglobin
B. White blood cell count
C. Platelet count
D. Blood glucose
Rationale: Before epidural placement, the platelet count must be assessed because
thrombocytopenia significantly increases the risk of epidural hematoma and spinal
cord compression. Low platelets (typically below 50,000–100,000/mm³, depending on
facility protocol) are a contraindication .
2. One hour after delivery, the nurse is unable to palpate the uterine fundus of
a client and notes a large amount of lochia on the perineal pad. Which
intervention should the nurse implement next?
A. Document the number of pad changes
B. Increase the rate of the oxytocin infusion
C. Palpate the suprapubic area for bladder distention
D. Provide a bedpan to void if unable to ambulate
Rationale: A boggy, displaced uterus with excessive lochia strongly suggests uterine
atony, most commonly caused by a full bladder. The bladder displaces the uterus
upward and to the right, preventing effective contraction. The nurse must first assess
for bladder distention; increasing oxytocin without emptying the bladder will be
ineffective .
3. A nurse is assessing a 2-hour-old newborn and notes a bluish tinge to the
tongue. Which action should the nurse take?
,A. Document the finding as acrocyanosis
B. Obtain current vital signs and notify the provider immediately
C. Apply a pulse oximeter to the foot
D. Reassess the infant in 30 minutes
Rationale: A bluish tinge to the tongue (central cyanosis) indicates systemic hypoxemia
and represents a life-threatening emergency, often due to right-to-left shunting in
congenital heart defects. Peripheral cyanosis (acrocyanosis) of the hands and feet is
common and less concerning, but central cyanosis takes priority .
4. A client at 30 weeks of gestation is on bed rest at home for increased blood
pressure. She calls the clinic complaining of "indigestion." Which instruction
should the nurse provide?
A. Take an antacid and call back if pain persists
B. Lie on the left side and call 911 for emergency assistance
C. Take your blood pressure now and if it is seriously elevated, go to the
hospital
D. See your healthcare provider for a prescription for a histamine blocker
Rationale: Indigestion in pregnancy, especially with a history of elevated blood
pressure, may signal serious complications like preeclampsia or cardiac issues. The
priority is to assess blood pressure to determine if emergency care is needed .
5. The nurse is evaluating a full-term multigravida who was induced 3 hours
ago. The monitor indicates that the fetal heart rate decelerates at the onset of
several contractions and returns to baseline before each contraction ends.
Which action should the nurse take?
A. Reapply the external transducer
B. Insert an intrauterine pressure catheter
C. Continue to monitor labor progress
D. Discontinue the oxytocin infusion
Rationale: The described pattern is early deceleration, which is caused by head
compression during contractions and is a benign finding. It mirrors the contraction and
returns to baseline before the contraction ends. No intervention is required other than
continued monitoring .
6. A new mother is having trouble breastfeeding. The newborn is making
frantic rooting motions and will not grasp the nipple. Which intervention by
the nurse would be most helpful?
A. Encourage the mother to continue attempting to latch despite the distress
B. Ask the mother to stop feeding, comfort the infant, and then assist the
,mother to help the baby latch on
C. Recommend formula supplementation until the infant is calmer
D. Suggest the mother pump and bottle-feed instead
Rationale: Frantic rooting and failure to grasp the nipple indicate the infant is overly
hungry or stressed, making effective latching impossible. The best approach is to calm
the infant first (skin-to-skin contact, gentle rocking) and then assist with proper
positioning and latch technique when the infant is more relaxed .
7. A nurse is caring for a client with suspected placental abruption. Which
finding is most consistent with this diagnosis?
A. Painless bright red vaginal bleeding
B. A rigid, board-like abdomen
C. Sudden severe pain with fetal distress in a client with a prior uterine scar
D. Regular uterine contractions before 37 weeks gestation
Rationale: A rigid, board-like abdomen in a pregnant client is a classic sign of abruptio
placentae (placental abruption), which occurs when the placenta separates prematurely
from the uterine wall. Placenta previa typically presents with painless, bright red
bleeding .
8. The healthcare provider prescribes magnesium sulfate 1 gram per hour IV for
a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in
dextrose 5% in water 500 mL. How many mL/hour should the nurse program
the infusion pump?
A. 10 mL/hour
B. 20 mL/hour
C. 25 mL/hour
D. 50 mL/hour
Rationale: The concentration is 20 grams in 500 mL = 0.04 grams/mL. The prescribed
dose is 1 gram/hour. Using the formula: 1 gram/hour ÷ 0.04 grams/mL = 25 mL/hour.
The nurse must monitor for magnesium toxicity (absent reflexes, respiratory
depression) and keep calcium gluconate available as the antidote .
9. A client at 38 weeks gestation reports a sudden gush of clear fluid from the
vagina. Which action should the nurse take first?
A. Check the fluid for a nitrazine reaction
B. Notify the healthcare provider
C. Assess the fetal heart rate
D. Perform a sterile speculum examination
, Rationale: After spontaneous rupture of membranes, the priority is assessing fetal well-
being because of the risk of umbilical cord prolapse. Checking fluid characteristics,
notifying the provider, and speculum examination are important but secondary to
confirming fetal safety .
10. A postpartum client who is Rh-negative gave birth to an Rh-positive
newborn but did not receive Rho(D) immune globulin. The nurse understands
this places the client at risk for which condition in a future pregnancy?
A. ABO incompatibility
B. Hemolytic disease of the newborn
C. Hyperbilirubinemia in the current newborn
D. Maternal thrombocytopenia
Rationale: Without Rho(D) immune globulin, an Rh-negative mother produces anti-Rh
antibodies that attack Rh-positive fetal red blood cells in a subsequent pregnancy,
causing hemolytic disease of the newborn .
11. A nurse is teaching a client about signs of preterm labor. Which statement
by the client indicates correct understanding?
A. "I should call if I feel regular contractions even without pain."
B. "Menstrual-like cramps are normal and not a concern."
C. "Low back pain is always just muscular."
D. "Increased vaginal discharge only means infection."
Rationale: Regular contractions, pelvic pressure, low back pain, menstrual-like cramps,
and changes in discharge may indicate preterm labor and should be reported .
12. A nurse is evaluating a client's understanding of home care for mastitis.
Which statement indicates a need for further teaching?
A. "I will finish all my antibiotics even if I feel better."
B. "I should stop breastfeeding from the infected breast."
C. "Warm compresses before feeding help with comfort."
D. "I will increase my fluid intake to stay hydrated."
Rationale: Breastfeeding or pumping from the infected breast helps empty it and
reduces bacterial stasis. Stopping worsens engorgement and infection. The client should
continue feeding from both breasts, starting on the unaffected side .
13. A client is admitted with suspected placental abruption. Which finding is
most consistent with this diagnosis?
A. Painless bright red vaginal bleeding
B. A rigid, board-like abdomen
